introduction to patient-reported outcome measures
Post on 30-May-2018
224 Views
Preview:
TRANSCRIPT
-
8/14/2019 Introduction to Patient-Reported Outcome Measures
1/33
Patient Reported Outcome
Measures
Dr Justin Whatling
2009
Visiting ProfessorCentre for Health Informatics &Multiprofessional Education
Routine Health Outcomes Ltd
Clinical Director
Routine Health Outcomes Ltdmeasuring health
-
8/14/2019 Introduction to Patient-Reported Outcome Measures
2/33
Agenda
Introduction to PROMs
Case studies
BUPA Case Study
howRU Case Study
Health utility exercise
-
8/14/2019 Introduction to Patient-Reported Outcome Measures
3/33
Measuring health
Healthcare here foronly 2 reasons
Live longer
Improve quality of life
Yet we only routinelymeasure mortality
3
Adding Years to Life and Life to Years
-
8/14/2019 Introduction to Patient-Reported Outcome Measures
4/33
Renewed interest
Routine HealthOutcomes Ltd
Linking revenue to outcomes showsthat DH is serious
Payment to hospitals for services is
being linked to patient-reportedexperiences and outcomes as oneway of driving improved quality andpatient-focus across the NHS
HM Government. Working Together PublicServices on Your Side. London: HMSO, March
2009
High Quality Care for All
If quality is to be at the heart of everything we do, itmust be understood from the perspective of the
patient.
Just as important [as clinical measures] is theeffectiveness of care from the patients ownperspective which will be measured throughPROMs
Darzi. High Quality Health For All: NHS Next Stage Review Final Report.London: Department of Health, 2008
The ultimate measure by which tojudge the quality of a medical effortis whether it helps patients (andtheir families) as they see it.
Donald Berwick, BMJ 1997
-
8/14/2019 Introduction to Patient-Reported Outcome Measures
5/33
Outcomes
Adapted from FDA/ Harmonisation meeting 16/02/01. Rockville MD
-
8/14/2019 Introduction to Patient-Reported Outcome Measures
6/33
What are PROMs
PROMs are questionnaire tools that measure patients health status
Measuring the same questionnaire over time enables comparison and change inhealth status to be assessed
Change in health status can be assessed against patient progress or healthinterventions received
Main types
Health Related Quality of Life, HRQL patients evaluation of the impact of a health condition and its treatment on relevant
aspects of life
Health Utility a cardinal measure of the preference for, or desirability of, a specific level of health status
or specific health outcome
Quality of life is subjective..
Given its inherently subjective nature, consensus was quickly reached that quality of life
ratings should, whenever possible, be elicited directly from patients themselves. NeilAaronson 1996
-
8/14/2019 Introduction to Patient-Reported Outcome Measures
7/33
From research to practice
Outcomes research seeks to understand the end resultsof particular healthcare practices and interventions.(Agency for Health Care Quality and Research, US Dept of Health and Human Science)
Outcomes management is the enhancement ofphysiologic and psychosocial patient outcomes throughdevelopment and implementation of exemplary healthpractices and services driven by outcomes assessment.(Wojner AW, President Health Outcomes Institute)
-
8/14/2019 Introduction to Patient-Reported Outcome Measures
8/33
Something
for everyone
Patients and families What is the likely outcome and recovery
path?
How am I doing?
What should I spend my personal healthbudget on?
Does my clinician really understand howI am feeling?
Routine HealthOutcomes Ltd
Commissioners Is this population group better than thatone?
Is there any difference in outcomebetween care providers?
How can we allocate resources to
achieve better value for money?
Clinicians Has this patients condition changed for
better or worse?
Am I missing something that is really
important for the patient?
How do my results compare withothers?
Support revalidation
Managers How do our results compare withothers?
What are we doing that provides little orno benefit?
How can we evaluate cost-saving
innovation to check that quality doesnot suffer?
Research What is the best treatment for this
condition?
What is the cost-effectiveness of an
intervention
-
8/14/2019 Introduction to Patient-Reported Outcome Measures
9/33
Outcomes Transparency
TheVirtuous
Circle
-
8/14/2019 Introduction to Patient-Reported Outcome Measures
10/33
PROM tools
Dimension specific
Single dimension such as function or pain e.g. Hospital anxiety and depression scale (HADS), McGill PainQuestionnaire
Disease/ Condition specific
Single condition
Thousands of specialised instruments
e.g. Arthritis Impact Measurement Scale (AIMS), Parkinson'sDisease Questionnaire (PDQ-39)
Generic
All conditions, all care settings
Relatively few instruments
e.g. Short Form-36, Sickness Impact Profile, EQ-5D
-
8/14/2019 Introduction to Patient-Reported Outcome Measures
11/33
History of Generic PROMs
First Generation (1968-1988) Measure health service output
Clinician as the rater
e.g. Rosser, Williams, RAND
Second Generation (1988-2008)
Clinical trials of pharma products, research
Patient as the rater
e.g. SF-36, SF-12, EQ-5D, HUI
Third Generation (2008-)
Routine use at point of care
e.g. howRU
Routine HealthOutcomes Ltd
-
8/14/2019 Introduction to Patient-Reported Outcome Measures
12/33
Measuring routine outcomes
-
8/14/2019 Introduction to Patient-Reported Outcome Measures
13/33
Beyond discrete surgical interventions
Routine health outcomes capture required
Scalable solutions required
-
8/14/2019 Introduction to Patient-Reported Outcome Measures
14/33
Approach
Objective fit for routine use
Quick and simple
Appropriate technology
Deliver value to care professionals and consumers New
Learn from mistakes of others
Limited evidence base so far Generic
Multiple conditions & care settings health care, social care, wellbeing, work
-
8/14/2019 Introduction to Patient-Reported Outcome Measures
15/33
Pain or discomfort
Feeling low or worried
What matters to us as patients
Limited in what you can do
Dependent on others
Routine Health Outcomes Ltd
-
8/14/2019 Introduction to Patient-Reported Outcome Measures
16/33
Routine Health Outcomes Ltd
howRU
-
8/14/2019 Introduction to Patient-Reported Outcome Measures
17/33
Length in words
Routine Health Outcomes Ltd
-
8/14/2019 Introduction to Patient-Reported Outcome Measures
18/33
Early Validation Study
Patients with 21 long term conditions
Telephone survey
Summer 2008 (beta version phone script) 2,908 subjects
Picker Institute
Comparison with SF-12
Routine Health Outcomes Ltd
-
8/14/2019 Introduction to Patient-Reported Outcome Measures
19/33
howRUPhone Script (beta version)
Wed now like to ask about how you are feeling today and how much you can do.
How are you today. do you have any of the following:
Symptoms, such as pain?none; slight; quite a lot; extreme.
Feeling low or worried?
none; slight; quite a lot; extreme.
Limited in what you can do?
none; slight; quite a lot; extreme.
Dependent on others?
none; slight; quite a lot; extreme.
-
8/14/2019 Introduction to Patient-Reported Outcome Measures
20/33
-
8/14/2019 Introduction to Patient-Reported Outcome Measures
21/33
Correlation 0.99
-
8/14/2019 Introduction to Patient-Reported Outcome Measures
22/33
-
8/14/2019 Introduction to Patient-Reported Outcome Measures
23/33
Correlation 0.97
-
8/14/2019 Introduction to Patient-Reported Outcome Measures
24/33
Psychometric properties Good internal structure, howRU
Item pair correlations are significant at the 0.01 level (2-tailed)
Average inter-item correlation is 0.50, at top end of the expected range
Suggests that the howRU dimensions are not independent and measure different aspects ofthe same underlying continuum
Support for a single summary score, howRU The correlations between each item and the aggregate howRU score have a mean of 0.61,
which are substantial and suggests that a single summary score is appropriate to use
Principal factor analysis of the howRUitems using maximum likelihood extraction suggeststhat a single latent dimension underlies these items
Supported by Cronbachs alpha, which is 0.8 (expect 0.7-0.9)
Good correlation with SF-12 Physical howRU dimensions are more highly correlated with PCS (mean 0.66), than with
MCS (mean 0.32) Mental howRU dimension is more highly correlated with MCS (0.59) than with PCS-12 (0.33)
The correlation between the aggregate howRUscore with the aggregate SF-12 score (sum ofPCS-12 and MCS-12) is 0.81
Exploratory principal components analysis: the component loadings suggest that howRUphysical dimensions together with PCS-12 load substantially onto one component, and that
howRU mental dimension and MCS-12 load onto the second (orthogonal) component.
-
8/14/2019 Introduction to Patient-Reported Outcome Measures
25/33
howRUProperties
Universal
All conditions, all care settings Takes almost no time
Seconds not minutes
Improves patient care helps patients and clinicians in routine use
Integrate with IT systems
Record linkage and risk adjustment
Easy to understand results
Simplicity
-
8/14/2019 Introduction to Patient-Reported Outcome Measures
26/33
-
8/14/2019 Introduction to Patient-Reported Outcome Measures
27/33
Health Economics
Comparing different allocations
What should we spend our money on Wheel chairs?
Cancer screening?
Can measure cost of inputs but not outputs cantput an economic value on healthcare
So we use cost-effective analysis
Measure costs and outcomes
Cost per outcome
-
8/14/2019 Introduction to Patient-Reported Outcome Measures
28/33
Quality Adjusted Life Years (QALY) Outcomes must be comparable
Disease specific outcomes are incompatible and onlyallow comparisons within a disease area Generic outcome are compatible and allow
comparisons between disease areas Best outcome we currently have is QALYs
Multiply life years with a quality of life index Perfect health 1.0 to death 0.0
Then can establish the Cost per QALY This is the metric used by NICE Stated range 20,000 - 30,000 per QALY
-
8/14/2019 Introduction to Patient-Reported Outcome Measures
29/33
QALY Example
A new wheelchair for elderly (iBOT) Increases quality of life = 0.1 10 years benefit
Extra costs: $3,000 per life year
QALY = Y x V(Q) = 10 x 0.1 = 1 QALY Costs are 10 x $3,000 = $30,000
Cost/QALY = $30,000/QALY
30
-
8/14/2019 Introduction to Patient-Reported Outcome Measures
30/33
Cost per QALY league tableIntervention / QALY
GM-CSF in elderly with leukemia 235,958EPO in dialysis patients 139,623
Lung transplantation 100,957
End stage renal disease management 53,513Heart transplantation 46,775
Didronel in osteoporosis 32,047
PTA with Stent 17,889
Breast cancer screening 5,147
Viagra 5,097
Treatment of congenital anorectal malformations 2,778
30
-
8/14/2019 Introduction to Patient-Reported Outcome Measures
31/33
How to measure utility
Ask the patient or members of the public?
Quality of life is subjective.. Given its inherently subjective nature, consensuswas quickly reached that quality of life ratings
should, whenever possible, be elicited directly frompatients themselves. Neil Aaronson 1996
VAS scores wheelchair patients 8.0, view of healthcontrols 8.3 (Scan J Rehab Med 1985)
Is health a consumer market where consumervalues count?
-
8/14/2019 Introduction to Patient-Reported Outcome Measures
32/33
How to measure utility
Indirect utility assessment
HUI, EQ-5D, SF-6D leading but with differentstrong and weak points
More states better sensitivity, large number of
health states requires statistical techniques Direct utility assessment
Standard Gamble, Time Trade Off, Person Trade
Off, Visual Analogue Scale
-
8/14/2019 Introduction to Patient-Reported Outcome Measures
33/33
Finally
Patient Reported Outcome Measures have multiplepractical uses, all driving to help improve the quality andcost-effectiveness of service provision to patients
Along with clinical outcomes and patient experience,they are an important piece of the healthcare jigsaw andas such are fundamental to health system transformation
www.routinehealthoutcomes.com
justinwhatling@routinehealthoutcomes.com
top related